Order Number For vaccine recipients: The following questions will help us determine if there is any reason you should not get the HPV vaccine today. It does not necessarily mean you should not be vaccinated. Additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it. Name * Mobile No. * DOB (D/M/Y) * Civil 1D / Passport No. * Address * MRJ Number GUARDIAN DETAILS (if applicable) Name Mobile No. DOB (D/M/Y) Civil 1D / Passport No. Address VACCINE RECIPIENT CHECKLIST The following questions will help us determine if there is any reason you should not get the vaccine today 1. Feeling sick today? Yes No 2. Complaining of a health condition or undergoing treatment that makes the recipient moderately or severely immunocompromised? (This would include treatment for cancer or HIV, receipt of organ transplant, immunosu- ppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant [HCT], DiGeorge syndrome or Wiskott-Aldrich syndrome) * Yes No 3. Have a history of allergic reaction: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing A severe reaction following any vaccine Yes No Any severe allergies Yes No Anaphylaxis to yeast Yes No If you answered yes to any of the above questions, please provide details 4. Check all that apply to the recipient Between ages 9 and 45 years old Have a bleeding disorder Receiving a blood thinner Have a history of heparin-induced thrombocytopenia (HIT) Currently pregnant or breastfeeding Have received dermal fillers Have a history of Guillain-Barr Syndrome (GBS) I hereby declare that the above information is accurate. I hereby declare that the above information is accurate.
